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Managed Care Expert Witnesses

Managed care arrangements allocate financial risk among health plans, providers, pharmacy benefit managers, employers, and government programs, and that allocation is a constant source of commercial litigation. Health plans and hospital networks dispute capitation and utilization, provider groups challenge reimbursement rates, risk adjustment, and network adequacy filings, plans pursue PBMs over rebate pass-through, self-funded employers contest stop-loss denials, and accountable care organizations litigate shared savings calculations. These disputes are contested because managed care contracts translate clinical activity into payment through complex formulas, coding rules, and data flows, and small differences in interpretation can move substantial sums between the parties.

A managed care expert reconstructs how the contract was supposed to work and compares that design to the claims, encounter, and payment data. The analysis may audit claims adjudication and coding, test whether utilization departed from capitation assumptions, reconcile rebate or shared savings calculations, or evaluate whether utilization management and prior authorization decisions followed the plan's own criteria and accepted practice. Where government programs are involved, the expert can assess compliance with Medicare Advantage risk adjustment rules or Medicaid managed care contract standards. That work allows counsel to establish breach, quantify underpayment or overpayment, and challenge an opposing expert's methodology on its own terms.

Managed care litigation requires an expert who has operated inside the contracting, reimbursement, and benefit administration functions now in dispute. Round Table Group's network includes health insurance executives who have testified on benefits administration and utilization management, managed care contracting specialists with deep experience in reimbursement and network development, and pharmacy benefit and pharmacoeconomics experts who have published on disease management and medication therapy management. It also includes biopharmaceutical market access professionals who have published on Medicare's drug competitive acquisition program and testified on pricing, reimbursement, and the commercial value of medicines. With more than 75,000 expert searches behind us, we can help you find the managed care expertise your matter calls for, and we would welcome the chance to discuss it by calling us at (202) 908-4500.

Kinds of Cases We Work On

Round Table Group helps our clients find a wide variety of Managed Care expert witnesses for cases like:

01

MCO Disputes Hospital Network Over Capitation Shortfall.

A managed care organization sued a hospital network, alleging the network's utilization of capitated specialty services significantly exceeded the utilization assumptions built into their capitation agreement, disrupting the MCO's risk-sharing calculations. We identified experts with experience in capitation agreement structuring, healthcare utilization analysis, and managed care risk-sharing methodology. The expert's utilization audit found a pattern of billing inconsistent with the capitation agreement's covered-service definitions, supporting the MCO's claim for reimbursement.
02

Insurer Disputes TPA Over Claims Processing Errors.

A health insurer sued its third-party claims administrator, alleging a systemic coding error caused a significant share of claims to be overpaid over an extended period, breaching the accuracy standards in their claims administration services agreement. We identified experts with experience in health claims administration standards, medical claims coding methodology, and third-party administrator agreement compliance. The expert's claims audit traced the errors to an outdated coding reference the administrator had failed to update, supporting the insurer's damages claim.
03

Health Plan Disputes PBM Over Rebate Shortfall.

A health plan sued its pharmacy benefit manager, alleging the PBM failed to pass through the full manufacturer rebate amounts owed under their pharmacy benefit management agreement, resulting in a significant shortfall in the plan's expected rebate revenue. We identified experts with experience in pharmacy benefit manager rebate accounting, drug formulary contracting, and PBM agreement compliance auditing. The expert's rebate reconciliation confirmed a pattern of underreported rebate amounts across several drug categories, supporting the health plan's claim for the shortfall.
04

Provider Network Disputes Plan Over Risk Adjustment Data.

A provider network sued a Medicare Advantage plan, alleging the plan's risk adjustment coding practices failed to capture chronic condition diagnoses the network had properly documented, resulting in underpaid risk-adjusted reimbursement under their value-based provider agreement. We identified experts with experience in Medicare Advantage risk adjustment methodology, HCC coding standards, and value-based care contract compliance. The expert's chart audit confirmed a pattern of properly documented conditions omitted from the plan's risk adjustment submissions, supporting the network's claim for underpaid reimbursement.
05

MCO Disputes State Agency Over Medicaid Contract Terms.

A managed care organization sued a state Medicaid agency, alleging the agency's revised network adequacy standards were applied retroactively to the MCO's existing Medicaid managed care contract in breach of the contract's amendment provisions. We identified experts with experience in Medicaid managed care contract compliance, network adequacy standards, and government health program regulatory analysis. The expert found the revised standards were adopted after the contract's current performance period began, supporting the MCO's claim against the agency.
06

Employer Disputes Stop-Loss Insurer Over Claim Denial.

A self-funded employer sued its stop-loss insurer after the insurer denied reimbursement for a large catastrophic claim, arguing a pre-existing condition exclusion applied despite the employer's contention that the condition had been properly disclosed during the policy's underwriting process. We identified experts with experience in stop-loss insurance underwriting standards, self-funded health plan claims analysis, and reinsurance policy interpretation. The expert's underwriting-file review confirmed the condition had been disclosed and accepted during underwriting, supporting a coverage ruling for the employer.
07

Provider Group Disputes Insurer Over Network Adequacy.

A physician provider group sued a health insurer, alleging the insurer's network adequacy filings misrepresented the group's actual appointment availability in a manner that breached the terms of their network participation agreement and exposed the group to regulatory scrutiny. We identified experts with experience in health insurance network adequacy standards, provider network filing compliance, and managed care regulatory analysis. The expert's appointment-availability audit found the insurer's filings overstated the group's actual capacity, supporting the provider group's claim against the insurer.
08

Health Plan Disputes Vendor Over Authorization System Failure.

A health plan sued a prior authorization software vendor after a platform outage during a system upgrade caused a backlog of pending authorization requests, delaying patient care and breaching the reliability guarantees in their software services contract. We identified experts with experience in prior authorization software systems, healthcare utilization management technology, and software service level agreement compliance. The expert's incident-log analysis confirmed the outage exceeded the contract's defined downtime threshold, supporting the health plan's claim for damages.
09

ACO Disputes Payer Over Shared Savings Calculation.

An accountable care organization sued a commercial payer, alleging the payer's shared-savings calculation methodology systematically excluded a category of qualifying quality-performance bonuses specified in their value-based care contract. We identified experts with experience in value-based care contract methodology, accountable care shared savings calculation, and healthcare quality performance measurement. The expert's performance-metric reconciliation confirmed the ACO's results warranted a larger distribution under the contract's own formula, supporting the ACO's claim for the shortfall.
10

Health Plan Disputes Vendor Over Credentialing Delays.

A health plan sued a provider credentialing vendor, alleging repeated unexplained delays in physician credentialing prevented several newly contracted providers from billing under the plan's network for months beyond the timeline specified in their credentialing services agreement. We identified experts with experience in healthcare provider credentialing standards, managed care network onboarding compliance, and vendor service agreement performance auditing. The expert's credentialing-timeline audit confirmed the delays exceeded the agreement's specified processing window, supporting the health plan's claim for damages.

Here are a few of our favorite Managed Care Expert Witnesses:

Florida Managed Care Expert #7794

I have 25 years of experience and specialize in the field of medicine with specific knowledge in the areas of managed care, pharmacy costs and emergency medicine. I have published on such topics as emergency medicine. I have testified on medical malpractice.

 

California Biotechnology, Managed Care Expert #19989

I have 25 years of experience, and specialize in the field of pharmaceuticals and biotechnology with specific knowledge in the areas of managed care, channels of distribution and marketing of pharmaceuticals and biotechnology products. I have published on such topics as managing pharmaceutical and biotechnology utilization and cost, the Centers for Medicare and Medicaid Services drug competitive acquistion program. I have testified on differential value of a medicine in the U.S. marketplace.

 

California Managed Care, Accounts Payable Expert #22355

I have 22 years of experience and specialize in the fields of accounting, operations, internal audit, and risk consulting, with specific knowledge of entertainment, business and accounting processes, and business risk.

 

Delaware Reimbursement, Managed Care Expert #24941

I have 25 years of experience, and specialize in the field of biopharmaceutical/medical device marketing with specific knowledge in the areas of brand strategy, pricing and reimbursement and product valuations. I have testified 9 times on topics such as patent infringement-commercial success, false advertising, bankruptcy-patent valuation and assess marketing strategies and product and Breach of contract-reasonable commercial efforts.

 

Virginia Health Insurance, Managed Care Expert #25029

I have 28 years of experience in the field of health insurance and managed health care, with specific knowledge of managed care, utilization management, and commercial health insurance administration. I have published on such topics as health care. I have testified on health benefits administration and utilization management.

 

Your Case Deserves The Best Managed Care Expert Witnesses

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The right expert witnesses and consulting experts can make your case. That’s why we have spent so many hours over the past quarter century making sure our clients have just the right expert team — whether one expert or many, early-stage advice or expert reports and testimony. Across over 50,000 expert search assignments, we have honed a unique, customized approach to identifying, analyzing and connecting with expert talent so you can focus on winning your case.

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Illinois Managed Care Expert #28471

I have 18 years of experience and specialize in the field of managed care, with specific knowledge of contracting, health care reimbursement and networks.

 

Florida Safety, Managed Care Expert #35213

I have 20 years of experience, and specialize in the field of pharmaceuticals with specific knowledge in the areas of medication safety, pharmacy benefits and pharmacoeconomics. I have published on such topics as disease management, pharmacoeconomics and medication therapy management.

 

California Uninsured, Managed Care Expert #40727

I have 30 years of experience, and specialize in the field of health administration with specific knowledge in the areas of health policy, managed care and health care marketing. I have published on such topics as uninsured health policy and programs, business intelligence and organ donation. I have testified 20 times on topics such as parental fitness, child abuse and neglect.

 

Nevada Managed Care Expert #43271

I have 10 years of experience, and specialize in the field of medical devices with specific knowledge in the areas of insulin pumps, continuous glucose monitoring devices and diabetes management software.

 

Put Our Managed Care Expert Network to Work for You

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Our huge network of experts – eminent university professors and practitioners who have achieved renown as thought leaders in their fields – combined with unparalleled research capabilities puts the experts you need at your disposal when and where you need them.

If you’re a litigator or general counsel, we want to put this network to work for you and your clients. Let us know how we can help by calling us at (202) 908-4500 or filling out the form on this page. We’re so confident you’ll love what we do that unless you retain an expert we present there’s no charge!

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Questions Attorneys Ask About Managed Care Expert Witnesses:

A managed care expert is warranted when payment, risk sharing, or contract performance between a health plan and its counterparties is in dispute. Typical matters include provider reimbursement and capitation disputes, PBM rebate and pricing claims, Medicare Advantage risk adjustment and Medicaid managed care contract disputes, stop-loss coverage denials, and claims against TPAs or utilization management vendors. Early involvement helps counsel secure the claims and encounter data needed to support the analysis.
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Spend your time working with your experts, not searching for them! We're here to de-stress the process of having a great expert witness team so that it’s easy to have the right experts every time. We'll conduct a quick but thorough search and deliver a roster of top candidates for you to review. There's no charge for the custom search — you pay only the hourly rate if you retain one of our experts.

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